Provider Demographics
NPI:1275956955
Name:ROBERTSON, CRYSTAL GOODMAN (IMFT)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:GOODMAN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:DAWN
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IMFT
Mailing Address - Street 1:190 CURRIE HALL PKWY
Mailing Address - Street 2:STE A
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4312
Mailing Address - Country:US
Mailing Address - Phone:330-673-5812
Mailing Address - Fax:330-673-7162
Practice Address - Street 1:190 CURRIE HALL PKWY
Practice Address - Street 2:STE A
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4312
Practice Address - Country:US
Practice Address - Phone:330-673-5812
Practice Address - Fax:330-673-7162
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF.1300011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist